Improving the System of Care for STEMI Patients

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Improving the System of Care for STEMI Patients
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List of Commonly Used Terms

• Electrocardiogram (ECG)A recorded tracing of the
  electrical activity of the heart
• Percutaneous Coronary Intervention (PCI)A
  procedure used to open or widen narrowed or
  blocked blood vessels supplying the heart
• ST-Elevation Myocardial Infarction (STEMI)A
  myocardial infarction for which the ECG shows
  ST-segment elevation, usually associated with a
  recently closed coronary artery
• FibrinolyticAn agent used to facilitate fibrin
  breakdown

• PCI Hospital/STEMI-Receiving CenterHospital
  that can perform primary PCI
• Non-PCI Hospital/STEMI-Referral CenterHospital
  that cannot perform primary PCI and may transfer
  to a center for primary PCI or use fibrinolytics
• ReperfusionThe restoration of blood flow to an
  organ or tissue. PCI and fibrinolytics are two
  types of reperfusion strategies.

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Types of Heart Attack

• Non-STEMI
• Non ST-elevation myocardial infarction
• Partially blocked artery
• Decreased blood flow to a portion of the heart
• STEMI
• ST-elevation myocardial infarction
• Completely blocked artery
• No blood flow to a portion of the heart
• Substantial risk of death and disability
• Critical need for quick reperfusion
• Restoration of blood flow by reopening the
  blocked artery

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Reperfusion Strategies for STEMI

• Plan A percutaneous coronary intervention
  (primary PCI)
• Mechanical means of restoring blood flow
• Balloon angioplasty
• Stents
• More effective
• Lower bleeding risk
• Available at only 25 of U.S. hospitals
• Treatment delays
• Plan B thrombolytics (fibrinolytics)
• Pharmacologic means of restoring blood flow
• Clot-busting drugs
• Less effective
• Greater bleeding risk
• Widely available at U.S. hospitals

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Reperfusion Recommendations

• STEMI patients presenting to a hospital with PCI
  capability should be treated with primary PCI
  within 90 minutes of first medical contact.

• STEMI patients presenting to a hospital without
  PCI capability and who cannot be transferred to a
  PCI center for intervention within 90 minutes of
  first medical contact should be treated with
  fibrinolytic therapy within 30 minutes of
  hospital presentation, unless contraindicated.

ACC/AHA 2007 STEMI Focused Update Circulation
2007 on line, December 10.
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Barriers to Timely Reperfusion

• The patient
• Failure to promptly recognize symptoms
• Hesitation to seek medical attention
• Time to transport
• Mandated delivery to the closest hospital,
  regardless of PCI capabilities
• Long transport in rural areas
• Decision process on arrival
• Clot-busting drugs vs. PCI
• Off hours
• Transfer to PCI facility
• Time to implement treatment strategy
• Procedural factors
• Team assembly

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The Reality of Todays Patients

• Not all STEMI patients call 9-1-1
• 50 of STEMI patients present to their local
  emergency department (ED)
• Walk-in patients hinder
• Registration
• Quick triage to electrocardiograms (ECG) for
  diagnosis
• ECG privacy
• Advance warning to activate hospital staff to
  prepare for reperfusion

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STEMI Door-to-Balloon and Door-to-Needle
TimesCumulative 12-Month Data from ACTION
Registry
ACTION DATA January 1, 2007 December 31. 2007
(n19,523) DTB 1st door to balloon for primary
PCI DTN Door to needle for lytics
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ACTION Median Door-to-Balloon TimesFor Transfer
In Non-Transfer In Patients
250
240
236
230
223
220
215
212
210
200
190
180
170
169
160
158
151
156
150
Time (min)
140
123
130
120
120
116
113
103
110
102
100
96
95
90
79
78
80
75
74
70
62
60
60
57
57
50
40
30
20
10
0
Q1 07
Q2 07
Q3 07
Q4 07
Transfer in DTB Times
Non-Transfer in DTB Times
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How do we increase the number of patients with
timely access to reperfusion therapy?
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A Life-Saving Initiative

• National, community-based initiative
• Goals
• Improve quality of care and outcomes in heart
  attack patients
• Improve health care system readiness and response
  

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Mission Lifelines Guiding Principles

• The initiative values
• Patient-centered care as the 1 priority
• High-quality care that is safe, effective and
  timely
• Stakeholder consensus
• Increased operational efficiencies
• Appropriate incentives for quality
• Measureable patient outcomes
• An evaluation mechanism
• A role for local community hospitals
• A reduction in disparities of healthcare delivery

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The Uniqueness of Mission Lifeline

• Mission Lifeline will
• Promote the ideal STEMI systems of care
• Help STEMI patients get the life-saving care they
  need in time
• Bring together healthcare resources into an
  efficient, synergistic system
• Improve overall quality of care
• The initiative is unique in that it
• Addresses the continuum of care for STEMI
  patients
• Preserves a role for the local STEMI-referral
  hospital
• Understands the issues specific to rural
  communities
• Promotes different solutions/protocols for rural
  vs. urban/suburban areas
• Recognizes there is no one-size-fits-all
  solution
• Knows the issues of implementing national
  recommendations on a community level

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STEMI Chain of Survival
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History2004-2006

• May 2004
• AHA recruited an Advisory Working Group (AWG)
• June 2005
• Price Waterhouse Coopers presents its market
  research to AWG
• March 2006
• AWG Consensus Statementappears in Circulation
• Stakeholders called to action
• AWG develops a set of guidingprinciples
• AHA held a conference of multidisciplinary groups
  involved in STEMI patient care

Circulation 20061132152-2163.
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History2007-Present

• Early 2007
• Drafts of STEMI Systems of Care manuscripts are
  finalized
• Action items for the AHA begin to take shape
• April 2007
• A cross-functional team was recruited to
  spearhead Mission Lifeline
• May 2007
• Eleven manuscripts are published in Circulation
• Mission Lifeline was formally launched
• July 2008
• Affiliate Staff Kick-Off was held

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The Ideal STEMI System of Care
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The Ideal Patient

• Patients and the public
• Recognize the symptoms of STEMI
• Realize the importance of
• Activating emergency medical services (EMS) via
  9-1-1 promptly
• Getting treatment quickly
• Are familiar with their local hospitals role in
  STEMI care
• Understand the implications of inter-hospital
  transfer for PCI
• The ideal system
• Promotes culturally competent education efforts
• Includes patient representatives on community
  planning coalitions
• Provides coordinated and patient-centered care

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The Ideal EMS

• In an ideal system
• Ambulances are equipped with 12-lead ECG machines
• EMS providers are trained to
• Use and transmit 12-lead ECGs
• Care for STEMI patients
• Provide feedback on performance and compliance
  with guidelines
• Standardized point-of-entry (POE) protocols
  define patient transport rules
• When there is STEMI, the cath lab is activated
  promptly
• Patients transported to a STEMI-referral hospital
  remain on the stretcher with EMS present pending
  a transport decision
• When walk-in patients present to a
  STEMI-referral hospital and require primary PCI,
  activation of EMS occurs
• Hospitals close the communication gap with EMS

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The Ideal STEMI-Referral Hospital

• In an ideal system
• Standardized POE protocols dictate transport of
  STEMI patients directly to a STEMI-receiving
  hospital based on
• Specific criteria for risk
• Contraindications to fibrinolysis
• The proximity of the nearest PCI service
• Patients presenting to a STEMI-referral hospital
  are treatedaccording to standardized triage and
  transfer protocols
• Incentives are provided to rapidly
• Treat STEMI patients in accordance with ACC/AHA
  guidelines
• Transfer to a STEMI-receiving hospital for
  primary PCI using
• Reperfusion checklists
• Standard pharmacological regimens and order sets
• Clinical pathways
• There is rapid and efficient data transfer, data
  collection and feedback
• Integrated plans for return of the patient to the
  community for care are provided

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The Ideal STEMI-Receiving Hospital

• In an ideal system
• Pre-hospital ECG diagnosis of STEMI, ED
  notification and cath lab activation occurs
  according to standard algorithms
• Algorithms facilitate
• A short ED stay for the STEMI patient
• Transport directly from the field to the cath lab
• Single-call systems from STEMI-referral hospitals
  immediately activate the cath lab
• Primary PCI is provided as routine treatment for
  STEMI 24, 7
• STEMI-receiving hospitals administration puts
  their support in writing
• A multidisciplinary team meets regularly to
  identify and solve problems
• A continuing education program is designed and
  instituted
• A mechanism for monitoring performance, process
  measures and patient outcomes is established

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POE Protocol
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Coordinated Actions

• Assess and improve the EMS system
• Evaluate existing STEMI system models
• Establish local initiatives
• Explore the possibility of developing a national
  STEMI-certification program and/or criteria
• Launch Mission Lifeline awareness campaigns
• Create system resources
• Engage strategic alliances

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Partners for Success

• Patients and care givers
• EMS providers
• Physicians, nurses and other providers
• STEM-referral (non-PCI) hospitals
• STEMI-receiving (PCI-capable) hospitals
• Health systems
• Departments of health
• EMS regulatory authority / office of EMS
• Rural health associations
• Quality improvement organizations
• Third-party payers
• State and local policymakers

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EMS System Assessment Improvement

• AHA is
• Collaborating with EMS organizations in a needs
  assessment
• Analyzing EMS effectiveness when responding to
  STEMI patients
• Developing a plan to build tailored STEMI systems
  of care

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STEMI System Evaluation Registration

• Online questionnaire
• Is accessible from the Mission Lifeline web
  site
• Examines local and regional STEMI system models
• Locale
• Processes of care
• Financial considerations
• Resource allocation
• Benefits
• Input can help Mission Lifeline target system
  issues where improvements will yield the greatest
  results

www.ahasurveys.com/se.ashx?s0B87B7ED7A3B4136
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Local Initiatives

• The American Heart Association is
• Convening a task force at state and local levels
• Helping identify ways to implement national
  recommendations for STEMI systems in local
  communities
• Registering STEMI systems with the Mission
  Lifeline directory

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STEMI Certification Recognition

• The American Heart Association will
• Develop recommendations for a certification
  program
• Generate and publish criteria to define a
• STEMI system of care
• EMS
• Non-PCI hospital
• PCI hospital
• Support policy approaches that advance the
  development of STEMI systems
• Develop a recognition program to
• Salute health care teams who comply with
  guidelines
• Commend STEMI systems for raising quality of care
• Help compliant hospitals differentiate themselves
• Motivate more health care providers to embrace
  the Mission Lifeline standards

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Implementation Plan

• Please visit www.americanheart.org/missionlifeline
  
• For each component of the system, Mission
  Lifeline will
• Define the ideal practice
• Recommend strategies to achieve the ideal
  practice
• Provide resources/tools to achieve the ideal
  practice
• Recommend metrics for structure, process and
  outcomes
• Recommend criteria for recognition and
  certification

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Implementation Phase 1
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Implementation Phase 2
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Implementation Phase 3
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How will we measure our impact?
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Mission Lifeline Metrics Data Sources

• EMS
• EMS assessment (NAEMSO and local assessments)
• ACTION/Get With The Guidelines (GWTG)
• NEMSIS
• Emergency department
• ACTION/GWTG Non-PCI Version
• STEMI-receiving (PCI-capable) hospitals
• ACTION/GWTG
• NCDR CATH/PCI registry

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Who is Mission Lifeline?
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Administrative Structure
Advisory Working Group Chair Alice Jacobs, MD
Model Evaluation Task Force Chair Elliott
Antman, MD
ECC Task Force Chair Robert O'Conner, MD
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Administrative Structure
Advisory Working Group Chair Alice Jacobs, MD
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Administrative Structure
ECC Task Force Chair Robert O'Conner, MD
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Administrative Structure
Model Evaluation Task Force Chair Elliott
Antman, MD
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AHA Staff
State Advocacy
State Health Alliances
Communications
Mission Lifeline
Quality Improvement
Development
Cultural Health Initiatives
ECC
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Organizational Commitment

• Current model Partial staff dedication
• State-level and hospital clinical quality
  improvement (QI) support
• State Health Alliance staff
• State Advocacy staff
• Quality Improvement staff
• Emergency Cardiovascular Care (ECC) Community
  Strategies managers
• Training of existing resources
• Initiative fundraising
• Current model State-level and hospital clinical
  QI support
• Programmatic support
• Stakeholder meetings and/or planning in all 50
  states
• ACTION/GWTG regional workshops
• Reactive advocacy agendas

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Increased Organizational Commitment

• State-level and hospital clinical quality
  improvement support
• PLUS
• Affiliate-level and market-level dedicated
  Mission Lifeline resources

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Strategic Alliances

• Aetna
• American Ambulance Association
• American Association of Critical Care Nurses
• American College of Cardiology
• American College of Emergency Physicians
• Centers for Medicare and Medicaid Services
• Emergency Nurses Association
• National Association of Emergency Medical
  Technicians

• National Association of EMS Physicians
• National Association of State EMS Officials
• National EMS Information System Project
• National Rural Health Association
• Society for Cardiovascular Angiography and
  Interventions
• Society of Chest Pain Centers
• Society of Thoracic Surgeons
• UnitedHealthNetworks

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Registered STEMI Systems

• Every day, new systems from all areas of the
  United States register with Mission Lifeline.
• STEMI systems will improve the quality of care
  for all myocardial infarction patients.
• http//www.americanheart.org/presenter.jhtml?ident
  ifier3059652

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